Nokea
A nurse is caring for a client who has been prescribed potassium. From the client's health history, the nurse understands that the client has also been taking salt substitutes. Which of the following conditions should the nurse monitor for in this client, occurring due to the interaction of the salt substitutes with potassium?
- A. Severe hemolytic reactions
- B. Elevated serum potassium levels
- C. Acute dehydration
- D. Severe hyperkalemia
Correct Answer: D
Rationale: The nurse should monitor the client's condition for signs and symptoms of severe hyperkalemia, which occurs due to the interaction of potassium with salt substitutes.
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A nurse is caring for a client who is receiving ammonium chloride. The nurse would be alert for the development of which of the following as a possible adverse reaction?
- A. Depressed reflexes
- B. Muscle weakness
- C. Circulatory collapse
- D. Metabolic acidosis
Correct Answer: D
Rationale: The nurse should monitor the client's condition for metabolic acidosis as an adverse reaction to ammonium chloride.
A client has been experiencing severe vomiting. The nurse notifies the primary health care provider based on the suspicion that the client may be developing hyponatremia. Which of the following would support the nurse's suspicion? Select all that apply.
- A. Increased skin turgor
- B. Hypotension
- C. bradycardia
- D. Anxiety
- E. Cold, clammy skin
Correct Answer: B,D,E
Rationale: Signs and symptoms of hyponatremia include clammy skin, decreased skin turgor, apprehension, confusion, irritability, anxiety, hypotension, postural hypotension, tachycardia, headache, tremors, convulsions, abdominal cramps, nausea, vomiting, and diarrhea.
After teaching a group of nursing students about electrolyte imbalances, the instructor determines that the teaching was successful when the group identifies which of the following as indicative of hypercalcemia? Select all that apply.
- A. Constipation
- B. Oliguria
- C. Polydipsia
- D. Bone pain
- E. Anorexia
Correct Answer: A,C,D,E
Rationale: Signs and symptoms of hypercalcemia include anorexia, nausea, vomiting, lethargy, bone tenderness or pain, polyuria, polydipsia, constipation, dehydration, muscle weakness and atrophy, stupor, coma, and cardiac arrest.
A client is receiving an IV infusion containing calcium. The nurse would monitor the client for which of the following as a possible adverse reaction? Select all that apply.
- A. Tingling
- B. Chalky taste
- C. Numbness
- D. Vein irritation
- E. Dry skin
Correct Answer: A,B,D
Rationale: When administering calcium IV, the client may experience irritation of the vein, tingling, a metallic or chalky taste, and 'heat waves.'
The use of an infusion pump or controller still requires nursing supervision and frequent monitoring of the IV infusion to monitor for signs of infiltration. Assessment of which of the following at the infusion site would lead the nurse to suspect that infiltration is occurring? Select all that apply.
- A. Edema
- B. Necrosis
- C. Burning
- D. Itching
- E. Redness
Correct Answer: A,E
Rationale: It is important for the nurse to monitor frequently for signs of infiltration while an infusion pump is in use. The signs of infiltration include edema and redness at the infusion site.